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Lateral Periodontal Cyst with Extremely Rare Clinical-Radiographic Presentation

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Lateral Periodontal Cyst with Extremely Rare Clinical-Radiographic Presentation Case Report Lateral periodontal cyst with extremely rare clinical-radiographic presentation Cisto periodontal lateral com apresentação clínico-radiográfica extremamente rara Abstract Marconi Eduardo S Maciel-Santos a Vinícius de Farias Pereira a a Purpose: The present article describes the clinical, radiographic and histological features of Pettely Thaíse de S Santos Palmeira a an extremely rare case of lateral periodontal cyst as well as the treatment and postoperative Diego Moura Soares Danielle Lago Bruno de Faria a follow-up. Uoston Holder da Silva a Case description: A 43-year-old male patient, mulatto, sought the Stomatology Clinic of the Caruaru Dental School (Brazil) with a complaint of increased volume on the right side of his face for approximately five years. The increase in volume was asymptomatic and facial asymmetry was the main reason he sought treatment. Based on the clinical and imaging exams as well as a ASCES College, Caruaru Dental School, Caruaru, the lack of pulp vitality in tooth 13, the presumed clinical diagnosis was inflammatory radicular PE, Brazil cyst and the surgical plan was total cystic enucleation. Excisional biopsy was performed and sent for pathologic microscopic analysis, which revealed multiple cavities with hyalinization of the connective tissue below the epithelium and the presence of clear non-epithelial cells. Conclusion: The case reported reveals that the extremely rare botryoid variant of lateral periodontal cyst exhibits multilocular presentation and excessive growth. Excisional biopsy was the treatment for this case and no sign of recurrence was observed over the nine-month follow-up period. Key words: Odontogenic cysts; periodontal cyst; Oral Pathology Resumo Objetivo: O presente artigo descreve os aspectos clínicos, radiológicos e histopatológicos de um caso extremamente raro de cisto periodontal lateral, bem como o tratamento e acompanhamento pós-cirúrgico. Descrição do caso: Um paciente masculino de 43 anos de idade, mulato, procurou a Clínica de Estomatologia da Faculdade de Odontologia de Caruaru (Brasil) queixando-se de grande aumento de volume no lado direito de seu rosto de aproximadamente cinco anos. Tal aumento de volume era assintomático e a assimetria facial foi o principal motivo pelo qual procurou o tratamento. Com base nos exames clínicos e radiográficos, bem como a falta de vitalidade pulpar no elemento 13, a hipótese diagnóstica foi de cisto radicular inflamatório e o plano cirúrgico envolveu a competa enucleação cística. A biópsia excisional foi realizada e enviada para análise histopatológica, a qual revelou múltiplas cavidades com hialinização do tecido conjuntivo abaixo do epitélio e presença de células não-epiteliais. Conclusão: O caso relatado revelou que a extremamente rara variação botrióide do cisto periodontal lateral possui aparência multilocular e crescimento excessivo. A biópsia excisional Correspondence: Marconi Eduardo Sousa Maciel Santos foi o tratamento para esse caso e nenhum sinal de recorrência foi observado durante o Av. Portugal, 584 – Bairro Universitário acompanhamento de nove meses. Caruaru, PE – Brazil Palavras-chave: Cistos odontogênicos; cisto periodontal; patologia bucal 55016-400 E-mail: [email protected] Received: November 29, 2010 Accepted: April 5, 2011 Conflict of Interest Statement: The authors state that there are no financial and personal conflicts of interest that could have inappropriately influenced their work. Copyright: © 2011 Maciel-Santos et al.; licensee EDIPUCRS. This is an Open Access article distributed under the terms of the Creative Commons Attribution- Noncommercial-No Derivative Works 3.0 Unported License. 176 Rev Odonto Cienc 2011;26(2):176-181 Maciel-Santos et al. Introduction The examination of the oral cavity revealed poor dental and periodontal status, with a number of missing teeth, calculus Lateral periodontal cyst (LPC) is an unusual cyst of build up, bleeding gums, gingival recession and advanced odontogenic origin, most frequently found in the mandible periodontitis. There was also an increased volume in the between the roots of canines and premolars and corresponding right vestibular region, extending from the area adjacent to to 0.7% to 1% of all cysts found in the jaw (1). This lesion tooth 13 to tooth 16. develops in the alveolar bone alongside an erupted vital The imaging exams (panoramic radiography and cone- tooth. As pain and other clinical signs are rarely reported beam volumetric tomography) revealed well-defined, (asymptomatic), this non-keratinized and non-inflammatory unilocular, radiolucent areas circumscribed by a radiopaque developmental cyst is diagnosed during routine radiographs, halo extending through the aforementioned areas and in which it exhibits a radiolucent image less than one cm adjacent to the apices of teeth 13 and 15 (Fig. 2). Due to the in diameter in most cases (1,2). Regarding incidence, there radiolucency, it was not possible to view the limits of the is a clear predominance among males in the fifth and sixth anterior wall or floor of the maxillary sinus. decades of life (3). Based on the clinical and imaging exams as well as the LPC is related to an adjacent vital tooth in most cases and lack of pulp vitality in tooth 13 (cold pulp vitality test), there is considerable difficulty in its identification following the presumed clinical diagnosis was inflammatory radicular endodontic treatment due to the possibility of lesion caused cyst and the surgical plan was total cystic enucleation and by infection of a lateral root canal (4). The origin of LPC is extraction of the damaged teeth involved. not fully known, but three likely possibilities are reported: Surgery occurred in a clinical setting with the patient reduced enamel epithelium, remnants of dental lamina and conscious and under local anesthesia with blockers. A cell rests of Malassez (5). semi-technical aspirating injection was performed with a The features of a lateral periodontal cyst can be easily disposable 20-ml syringe and 25-G needle, which revealed confused with a odontogenic keratocyst developing between a semi-solid content with citrine yellow coloration and roots or a more lateral radicular cyst. Thus, in addition to cholesterol crystals. From these findings, a modified clinical and radiographic findings, histopathological analysis Neumann incision was employed, pulling back the muco- is essential for the diagnosis of the lesion (6). Histologically, periostal flap to reveal the edges of the cyst, which was LPC is characterized by a thin layer of non-keratinized delimited and had a well-defined capsule. Enucleation epithelium and thick cell layer, which resembles reduced was performed with no serious complications. Tooth 13 enamel epithelium. Inflammation is not one of its aspects and the remaining root from tooth 15 were also removed and the walls consist of fibrous collagen tissue (4). during the same operation. Following the enucleation, Regarding the differential diagnosis, botryoid odonto- curettage and cleaning of the cavity, the surgical wound genic cyst (an uncommon lesion of the jaw bones) is was closed with simple stitches along the incision considered a multilocular variant of lateral periodontal cyst lines (Fig. 3). due to its microscopic presentation. The distinction is due Excisional biopsy was the treatment for the lesion in to the presence of multiple pathologic cavities, which give question, which was sent for pathological analysis. The it a multicystic appearance (7). For unknown reasons, the material consisted of a piece approximately 25 mm x 35 mm recurrence rate of botryoid cyst ranges from 15 to 33% at its largest point. Microscopically, there was the presence greater than that for LPC.2 Botryoid cysts are routinely of multiple cavities, with hyalinization of the connective treated with enucleation (1). tissue below the epithelium and the presence of clear non- The present study describes the clinical, radiographic epithelial cells (Fig. 4). The diagnosis was the botryoid and histological features of an extremely rare case of lateral variant of lateral periodontal cyst. periodontal cyst as well as the treatment and postoperative Postoperative control was rigorous for this case and follow-up. follow up was initially carried out on a weekly basis. After seven days, the patient exhibited a significant reduction in Description of the Case facial volume and had no important complaints. The surgical wound was satisfactory, with no signs of complications A 43-year-old male patient, mulatto, sought the that would justify the removal of the stitches. At 14 days, Stomatology Clinic of the Caruaru Dental School (Brazil) there was a significant reduction in swelling in the area and with a complaint of increased volume on the right side of his adequate healing for the time elapsed since the surgery and face for approximately five years, having emerged with no a new panoramic radiograph was solicited (Fig. 5). apparent cause. The increase in volume was asymptomatic Two months following the enucleation of the cyst, and facial asymmetry was the main reason he sought radiographic findings revealed areas of osteogenesis and treatment. the region was clinically satisfactory, as expected for this The extra-oral exam revealed a considerable increase interval. This condition remained stable at the five-month in volume on the entire right side of the face, involving the and nine-month follow up evaluations, with no sign of infra-orbital and zygomatic regions, with blurring of the recurrence
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